Patient: WREN, NANCY

Pathologist: Denise A Barbuto, M.D. Assistant:

Date of Procedure: 5/24/2007 Date Received: 5/25/2007

Ordering M.D.: RONALD S. LEUCHTER

***** AMENDED REPORT *****

Reason for Amendment/Correction #1: Additional sections or stuah DIAGNOSIS:

A. OMENTUM, OMENTECTOMY: - Metastatic serous carcinoma (see comment)

B. FALLOPIAN TUBE AND OVARY, LEFT, SALPING0-00PHORECTOMY:
Ovary virtually replaced by high grade (grade 3) serous carcinoma (see comment)

• Tumor also focally involves the serosal surface of the ovary
• Multiple nodular aggregates of similar-appearing tumor in para-ovarian/paratubal soft tissues
• Serosal surface, lymphovascular, muscular wall, and mucosal involvement of fallopian tube by serous carcinoma and foci of serous intraepithelial carcinoma of fallopian tube (see comment)
• Fallopian tube also shows foci of epithelial hyperplasia with and without associated cellular atypia, acute and chronic inflammation, and focal accumulation of hemosiderinladen macrophages
• Adnexal (paratubal) wolffian duct remnants

• Ovary showing partial replacement by high-grade serous carcinoma (about 1 cm diameter tumor nodule), ? synchronous primary lesion versus metastasis from contralateral adnexa
• No serosal surface involvement of ovary by tumor
• No evidence of metastatic carcinoma involving fallopian tube
• Ovary also shows atrophic changes, mild (relative) cortical stromal hyperplasia, cystic epithelial inclusions, and serosal adhesions, some hemorrhagic
• Fallopian tube with foci of mild epithelial hyperplasia without significant atypia
• Paratubal region also shows endosalpingiosis, cyst lined by benign serous epithelium (hydatid of Morgagni), multiple cystic Walthard rests, Wolffian duct remnants, and focal (microscopic) adenofibromatous changes
• Benign endometrial polyp
• Endometrium with weakly proliferative to proliferative features a few cystically dilated glands, and extensive autolytic changes; latter precluding reliable pathologic assessment in some areas
• Uterine adenomyosis
• Uterine serosal adhesions
• Cervix with tiny benign endocervical polyps, chronic and mild acute inflammation, reserve cell hyperplasia, squamous metaplasia, degenerative squamous changes, cystic endocervical tunnel clusters, and nabothian cysts

E. PERIURETERAL REGION, LEFT, "TUMOR", EXCISION:
- Metastatic serous carcinoma (see comment)

F. LYMPH NODES, LEFT PELVIC, EXCISION: - Two reactive lymph nodes - No evidence of metastatic carcinoma (0/2)

G. LYMPH NODE, RIGHT PELVIC, EXCISION: - One reactive lymph node - No evidence of metastatic carcinoma (0/1)

COMMENT: Pathologic ovarian tumor stage (AJCC Staging Manual Sixth Edition/2002) is assigned as follows: pT3c, NO, MX. Some of the tumor deposits involving the left fallopian tube represent obvious metastasis; however, at the fimbriated end of the fallopian tube where there is more extensive involvement of the wall and mucosa of the fallopian tube, the possibility of a synchronous tubal neoplasm cannot be excluded. In most of the involved sites the tumor exhibits predominantly solid growth. Papillary and focal glandular growth patterns are also noted. Lymphovascular invasion by carcinoma is present in virtually all of the involved sites. Tumor-associated necrosis and secondary acute and chronic inflammatory changes are present. In some of the involved sites there are secondary adhesions and/or reactive mesothelial changes. Summarized pathologic findings were reported to the office of Dr. Ronald Leuchter (telephone message left) on 05/31/07.

EXPLANATION OF CORRECTION/AMENDMENT: The summary of additional sections of the right fallopian tube (submitted in blocks C7, C8 and C9) was omitted from the list of sections following the gross description for specimen C and has now been added to that section of the report. (The findings in these additional sections had already been incorporated into the original diagnosis, despite the lack of listing of the sections.) There is no change in the diagnosis.

HISTORY: G5 P3 with history irregular bleeding x10 years, history hormone therapy x5 years, hypothyroidism

MICROSCOPIC: See diagnosis.

SPECIAL STUDIES: H&E-stained step sections (B1 x2, CI x2)

IMMUNOSTAINS: None

GROSS:
A. OMENTUM

Labeled with the patient's name, labeled "omentum", and received fresh in the Operating Room for intraoperative gross consultation and subsequently fixed in formalin is a 35.0 x 12.0 x 2.0 cm portion of yellow lobulated omental fat that shows numerous nodular and plaque-like aggregates of firm tan-white tumor. The individual tumor deposits measure up to 5.5 cm in diameter. Representative sections are submitted.

Labeled with the patient's name, designated "left tube and ovary", received fresh in the Operating Room for intraoperative gross consultation and subsequently fixed in formalin is a salpingo-oophorectomy specimen. The ovary is enlarged, about 7.5 x 5.0 x 5.0 cm. The serosal surface of the ovary is tan, undulated to bosselated and focally bloodied. There are tiny nodular deposits of semisoft tan tumor, measuring up to about 0.2 cm in diameter on the surface. Cut surfaces of the ovary are virtually replaced by tan-white to tan-yellow tumor. Most of the tumor is firm and solid, but there are softer areas that appear necrotic. Virtually no normal ovarian parenchyma is evident on gross inspection of the specimen. The adjacent fallopian tube has funbria at one end, is about 6.0 cm long and ranges from about 0.4 to 2.0 cm in diameter. The distal (fimbriated) end of the fallopian tube is expanded and involved by friable soft tan papillated and some firmer solid tan-white tumor. Within the ligamentous paraovarian and paratubal soft tissues, there are multiple additional nodular aggregates of firm tan tumor, ranging from about 0.3 to 1.5 cm in diameter. Representative sections are submitted.

Bl. Fallopian tube and adjacent adnexal soft tissues with tumor - 2
B2, B3. Ovary with tumor - 1 each
B4. Uninvolved proximal fallopian tube - 6
B5. Uninvolved mid portion of fallopian tube - 6
B6. Mostly uninvolved distal segment of fallopian tube and paratubal cyst - multiple
B7, B8. Possible fallopian tube with tumor - 2 each
B9, B10. Possible fallopian tube and paratubal tissues with tumor - 1 each

C. UTERUS AND CERVIX AND RIGHT TUBE AND OVARY

Labeled with the patient's name, designated "uterus and cervix and right tube and ovary", and received in fonnalin is a 115 gram total hysterectomy and right salpingo-oophorectomy specimen. The ovary is 2.5 x 1.5 x 1.0 cm and has an undulated tan-yellow serosal surface. Cut sections of the ovary reveal a nodular aggregate of tan-white tumor that is about 1.0 cm in diameter. There is focal hemorrhage adjacent to tumor in the ovary. The adjacent fallopian tube has fimbria at one end, is 6.5 cm long and ranges from 0.5 to 0.6 cm in diameter, has a smooth pink-tan serosal surface and a patent lumen that measures up to about 0.2 cm in diameter. The fallopian tube appears grossly free of tumor. The uterus is 8.5cm from the fundus to the ectocervix, 5.5 cm from comu to comu, and up to 4.5 cm from the anterior surface to the posterior surface. The uterine serosa is tan-red and generally smooth, except for focal procedure-related artifacts. The cervix is about 3.5 cm long and up to 3.0 cm in diameter in the ectocervical region. The mucosa lining the ectocervix is tan and smooth. The external cervical os is patent and about 0.9 cm in diameter. The cervical transformation zone is distinct. The endocervical canal is about 2.8 cm long and lined by soft tan rugose mucosa. There is a 0.6 cm diameter soft tan endocervical polyp, posteriorly. Cut sections of the cervix reveal several mucous-filled cysts, up to 0.3 cm in diameter, but no gross evidence of tumor. The endometrial cavity is about 4.0 cm long and up to 2.3 cm in width. Based in the anterior uterine corpus, there is a 3.0 x 1.0 x 0.2 cm focally hemorrhagic soft tan-red endometrial polyp. Elsewhere the endometrial mucosa is flatter, tan and has a maximum thickness of about 0.2 cm. The muscular uterine wall has a maximum thickness of about 2.2 cm. The myometrium is tan, firm and focally trabeculated. No leiomyomas are identified. The uterus appears grossly free of tumor. Representative sections are submitted.

Cl. Right ovary and fallopian tube - 3
C2. Anterior cervix - 1
C3. Posterior cervix with endocervical polyp - 1
C4. Anterior uterine corpus -1
C5. Anterior endometrial polyp - 1
C6. Posterior uterine corpus - 1

ADDITIONAL SECTIONS:

C7. Proximal right fallopian tube - 5
C8. Mid portion of right fallopian tube - 5
C9. Distal portion of right fallopian tube, including fimbria, and paratubal cysts - 4

D. RECTOSIGMOID TUMOR

Labeled with the patient's name, designated "rectosigmoid tumor", and received in formalin is a 1.5 x 1.0 x 0.3 cm irregular shaped fragment of tan-yellow soft tissue that is partially replaced by nodular aggregates of semifum tan tumor. The entire specimen is submitted. Dl. 1

E. LEFT PERTURETERAL TUMOR

Labeled with the patient's name, labeled "left periureteral tumor", and received in formalin, is a 2.2 x 1.5 x 1.5 cm nodular aggregate of firm tan tumor with scant attached uninvolved pink-tan soft tissue. Representative sections are submitted. El. 2

F. LEFT PELVIC LYMPH NODE

Labeled with the patient's name, labeled "left pelvic lymph node", and received in formalin is a 2.0 x 0.8 x 0.5 cm portion of soft yellow fatty tissue within which there are embedded two semisoft tan lymph nodes, measuring about 0.3 and 0.9 cm in maximum dimension. The entire specimen is submitted.

Fl . Two lymph nodes and fat -1

G. RIGHT PELVIC LYMPH NODE Labeled with the patient's name, labeled "right pelvic lymph node", and received in formalin is a 1.5 x 1.1 x 0.3 cm aggregate of soft yellow fatty tissue within which there is embedded a single semisoft tan lymph node that is about 1.1 cm in diameter. The entire specimen is submitted.

G1. One lymph node and fat -1

Gross dictated by Omar Mostafa, PA:amc:lg 05/29/07 Gross dictated by Omar Mostafa, PA:dp (addl) 05/31/07